Laura R. Carucci

ACR appropriateness Criteria® right lower quadrant pain - Suspected appendicitis

The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narratives focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Radiographic imaging of inflammatory bowel disease

Radiographic imaging studies have an important role in the workup of patients with suspected IBD and in the differentiation of ulcerative colitis and Crohns disease. Because of its ability to depict fine mucosal detail, the double-contrast barium study is a valuable technique for diagnosing ulcerative colitis and Crohns disease even in patients with early disease. In contrast, cross-sectional imaging studies such as CT, MR, and ultrasound are useful for showing the effects of these conditions on the wall of the bowel and also for demonstrating intra-abdominal abscesses and other extraluminal findings in patients with more advanced disease. Thus, barium studies and cross-sectional imaging studies have complementary roles in the evaluation of these patients.

Imaging of Bariatric Surgery: Normal Anatomy and Postoperative Complications

Obesity is a disease that has reached epidemic proportions in the United States and around the world. During the past 2 decades, bariatric surgery has become an increasingly popular form of treatment for morbid obesity. The most common bariatric procedures performed include laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy. Fluoroscopic upper gastrointestinal examinations and abdominal computed tomography (CT) are the major imaging tests used to evaluate patients after these various forms of bariatric surgery. The purpose of this article is to present the surgical anatomy and normal imaging findings and postoperative complications for these bariatric procedures at fluoroscopic examinations and CT. Complications after Roux-en-Y gastric bypass include anastomotic leaks and strictures, marginal ulcers, jejunal ischemia, small bowel obstruction, internal hernias, intussusception, and recurrent weight gain. Complications after laparoscopic adjustable gastric banding include stomal stenosis, malpositioned bands, pouch dilation, band slippage, perforation, gastric volvulus, intraluminal band erosion, and port- and band-related problems. Finally, complications after sleeve gastrectomy include postoperative leaks and strictures, gastric dilation, and gastroesophageal reflux. The imaging features of these various complications of bariatric surgery are discussed and illustrated.

Imaging obese patients: problems and solutions.

Obesity is an epidemic in the United States and Western World with an associated increasing impact on radiology departments. The increased prevalence of obesity in conjunction with the growing use and success of bariatric surgery results in an influx of obese patients into the health system in need of hospital services and care. Imaging services in particular are in demand in this patient population. Obese patients place special needs upon facilities and imaging equipment and also create technical challenges. This manuscript will address problems and potential solutions for imaging obese patients, specifically with regards to the modalities of radiography, fluoroscopy, computed tomography, and magnetic resonance imaging.

Pancreatic metastasis from clear cell renal carcinoma: Diagnosis with chemical shift MRI

Some clear cell renal cell carcinomas contain intracellular lipid, which can be detected with chemical shift MRI. We present an example of surgically proven metastatic clear cell renal carcinoma to the pancreas, which was diagnosed using chemical shift MRI.

Internal Hernia Following Roux-en-Y Gastric Bypass Surgery for Morbid Obesity: Evaluation of Radiographic Findings at Small-Bowel Examination

PURPOSE To characterize features of internal hernia (IH) at small-bowel follow-through (SBFT) following Roux-en-Y gastric bypass procedure (RYGBP) for morbid obesity. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant retrospective study; informed consent was waived. Radiologic database review revealed 1655 SBFT studies over 6 years in 1282 patients after RYGBP. IH was suggested on 24 studies in 23 patients. Studies were analyzed for atypical bowel configuration, change in bowel or suture position, and obstruction. Chart review was performed to determine clinical course, treatment, and outcome. Studies from a control group of 21 RYGBP patients were similarly analyzed. Statistical comparison was performed with the Fisher exact test. RESULTS Clinical and/or surgical evidence of IH was found following 21 SBFT studies in 20 of 1282 patients (1.6%). Atypical bowel configuration with clustered small bowel was identified on all studies. Cluster location was lateral to descending colon (n = 10), left upper quadrant (n = 6), left upper and mid abdomen (n = 3), right midabdomen (n = 2), under the gastric pouch (n = 1), and right lower quadrant (n = 1). For two studies, two locations of clustered bowel were identified. Change in jejunojejunal suture position occurred in all cases with radiopaque suture (n = 15). Other signs of IH included displaced colon (n = 19), visible entrance and exit limbs into the hernia (n = 17), stasis in clustered bowel (n = 16), densely matted bowel (n = 12), and a straight left lateral border of clustered bowel (n = 10). Partial obstruction occurred in 16 patients. Findings of atypical bowel configuration, clustered bowel, and staple line change were significant when compared with the control. CONCLUSION IH following RYGBP is a rare but potentially fatal complication. Radiologists must be aware of this complication and its diagnostic features at SBFT.

Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of leak into excluded stomach with upper gastrointestinal examination.

PURPOSE To retrospectively evaluate the imaging features at upper gastrointestinal (GI) examination of leak into the excluded part of the stomach after the Roux-en-Y gastric bypass (RYGB) procedure and to determine the associated complications and consequences of acute versus delayed leak development. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant study; the need for informed consent was waived. Database review revealed 1655 upper GI studies performed over 6 years in 1282 patients after an RYGB procedure. Leak into the excluded stomach was diagnosed in 48 patients (39 women, nine men; age range, 29-62 years; mean age, 46 years); these patients formed our study group. Studies were analyzed by two radiologists in consensus for extent and pattern of leak into the excluded stomach and the presence of associated complications of extraluminal leak or fistula, obstruction, and acute distention of the excluded stomach. Chart review was performed to determine clinical course, treatment, associated complications, and outcome. Patients were divided into two categories on the basis of acute versus delayed development of leak into the excluded stomach. Acute leak into the excluded stomach was diagnosed within 2 months of surgery. Delayed leak occurred more than 2 months after surgery. RESULTS Leak into the excluded stomach occurred in the acute postoperative period (within 2 months) in 25 of the 48 patients (52%) and was associated with extraluminal leak in 22 of those 25 patients (88%). Acute leak into the excluded stomach healed in seven of the 25 patients (28%). Delayed postoperative leak into the excluded stomach occurred in 23 of the 48 patients (48%) and resulted in failed weight loss in 14 of those 23 patients (61%). Fourteen of the 48 patients (29%) underwent surgical revision for leak into the excluded stomach. CONCLUSION Leak into the excluded stomach was identified on upper GI studies in 48 of 1282 patients (3.7%) after RYGB for morbid obesity. Acute leak into the excluded stomach may heal spontaneously; however, remote postoperative leak into the excluded stomach can result in failed weight loss and subsequent failure of the RYGB procedure.

ACR Appropriateness Criteria Crohn Disease

Crohn disease is a chronic inflammatory disorder involving the gastrointestinal tract, characterized by episodic flares and times of remission. Underlying structural damage occurs progressively, with recurrent bouts of inflammation. The diagnosis and management of this disease process is dependent on several clinical, laboratory, imaging, endoscopic, and histologic factors. In recent years, with the maturation of CT enterography, and MR enterography, imaging has played an increasingly important role in relation to Crohn Disease. In addition to these specialized examination modalities, ultrasound and routine CT have potential uses. Fluoroscopy, radiography, and nuclear medicine may be less beneficial depending on the clinical scenario. The imaging modality best suited to evaluating this disease may change, depending on the target population, severity of presentation, and specific clinical situation. This document presents seven clinical scenarios (variants) in both the adult and pediatric populations and rates the appropriateness of the available imaging options. They are summarized in a consolidated table, and the underlying rationale and supporting literature are presented in the accompanying narrative. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Consensus Statement of Society of Abdominal Radiology Disease-Focused Panel on Barium Esophagography in Gastroesophageal Reflux Disease

OBJECTIVE The Society of Abdominal Radiology established a panel to prepare a consensus statement on the role of barium esophagography in gastroesophageal reflux disease (GERD), as well as recommended techniques for performing the fluoroscopic examination and the gamut of findings associated with this condition. CONCLUSION Because it is an inexpensive, noninvasive, and widely available study that requires no sedation, barium esophagography may be performed as the initial test for GERD or in conjunction with other tests such as endoscopy.

ACR Appropriateness Criteria® Colorectal Cancer Screening

Colorectal cancer is the third leading cause of cancer deaths in the United States. Most colorectal cancers can be prevented by detecting and removing the precursor adenomatous polyp. Individual risk factors for the development of colorectal cancer will influence the particular choice of screening tool. CT colonography (CTC) is the primary imaging test for colorectal cancer screening in average-risk individuals, whereas the double-contrast barium enema (DCBE) is now considered to be a test that may be appropriate, particularly in settings where CTC is unavailable. Single-contrast barium enema has a lower performance profile and is indicated for screening only when CTC and DCBE are not available. CTC is also the preferred test for colon evaluation following an incomplete colonoscopy. Imaging tests including CTC and DCBE are not indicated for colorectal cancer screening in high-risk patients with polyposis syndromes or inflammatory bowel disease. This paper presents the updated colorectal cancer imaging test ratings and is the result of evidence-based consensus by the ACR Appropriateness Criteria Expert Panel on Gastrointestinal Imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.